File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT APPLICATION FORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.

Service Required

Application Reference Number 24-0004498044

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details

PRIYADARSHAN CHANDRAKANT
Applicant's Name
SHEDGE

Date of Birth (DD/MM/YYYY) 07/04/1988

Validity Required NA

Place of Birth (Village/Town/City) MUMBAI

District MUMBAI
Signature/Left Hand Thumb Impression
State/UT MAHARASHTRA of Illiterate Applicant and Minors who
cannot sign.
Region/Country INDIA

Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

PAN ECQPS5342D

Employment Type OTHERS

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? N

Aadhaar Number 891782868221

Family Details

Father's Name CHANDRAKANT MAHADEO SHEDGE

Mother's Name SHARDA CHANKRANAT SHEDGE

Spouse's Name POURNIMA PRIYADARSHAN SHEDGE
Present Residential Address Details

C111 SHIV SHAKTI APT. ANAND NAGAR, VASAI, PALGHAR,

Address
MAHARASHTRA

PIN 401202

Police Station PALGHAR

Mobile/Tel No. 9172582518

E-mail PRIYADARSHAN.SHEDGE@GMAIL.COM
Permanent Residential Address

C111 SHIV SHAKTI APT. ANAND NAGAR, VASAI, PALGHAR,

Address
MAHARASHTRA

PIN 401202

Police Station PALGHAR

Mobile/Tel No. 9172582518

Emergency Contact Details

Name and Address SUDARSHAN SHEDGE

Mobile/Tel No. 8149706791

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport

Passport Number Z2942578

Date of Issue 15/07/2014

Date of Expiry 14/07/2024

Place of Issue VASAI

Other Details
Payment Details

Mode of Payment Debit/Credit Card

Date 16/03/2024

Receipt/Reference No. CPADQDARC0

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)

Enclosures

1.A declaration given by the Head of the Orphanage/Child Care Home on their official letter head of the organization confirming the
DOB of the applicant

2.Aadhaar Card (Address Proof)

3.Affidavit stating how and where the Passport got lost/ damaged as per Annexure F
Self Declaration

I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any
other country. I have not lost, surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing
any material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my
application for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. I
am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to
furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me
in the form is bonafide.

Place VASAI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 10/03/2024 to sign)

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